Blood pressure response to standing is a strong determinant of masked hypertension in young to middle-age individuals

General Principles, Etiologies, Evaluation, and Management in Older Adults

Hypertension impacts most older adults as one of many multiple chronic conditions. A thorough evaluation is required to assess overall health, cardiovascular status, and comorbid conditions that impact treatment targets. In the absence of severe frailty or dementia, intensive treatment prevents more cardiovascular events than standard treatment and may slow cognitive decline. "Start low and go slow" is not the best strategy for many older adults as fewer cardiovascular events occur when hypertension is controlled within the first 3 to 6 months of treatment.

Assessment and management of exaggerated blood pressure response to standing and orthostatic hypertension: consensus statement by the European Society of Hypertension Working Group on Blood Pressure Monitoring and Cardiovascular Variability

Recent evidence suggests that an exaggerated blood pressure (BP) response to standing (ERTS) is associated with an increased risk of adverse outcomes, both in young and old individuals. In addition, ERTS has been shown to be an independent predictor of masked hypertension. In the vast majority of studies reporting on the prognostic value of orthostatic hypertension (OHT), the definition was based only on systolic office BP measurements. This consensus statement provides recommendations on the assessment and management of individuals with ERTS and/or OHT. ERTS is defined as an orthostatic increase in SBP at least 20 mmHg and OHT as an ERTS with standing SBP at least 140 mmHg. This statement recommends a standardized methodology to assess ERTS, by considering body and arm position, and the number and timing of BP measurements. ERTS/OHT should be confirmed in a second visit, to account for its limited reproducibility. The second assessment should evaluate BP changes from the supine to the standing posture. Ambulatory BP monitoring is recommended in most individuals with ERTS/OHT, especially if they have high-normal seated office BP. Implementation of lifestyle changes and close follow-up are recommended in individuals with ERTS/OHT and normotensive seated office BP. Whether antihypertensive treatment should be administered in the latter is unknown. Hypertensive patients with ERTS/OHT should be managed as any other hypertensive patient. Standardized standing BP measurement should be implemented in future epidemiological and interventional studies.

Healthy overweight and obesity in the young: Prevalence and risk of major adverse cardiovascular events

AIMS

To investigate the prevalence of metabolically healthy overweight/obesity and to study its longitudinal association with major adverse cardiovascular and renal events (MARCE).

METHODS AND RESULTS

The study was conducted in 1210 young-to-middle-age subjects grouped according to their BMI and metabolic status. The risk of MARCE was evaluated during 17.4 years of follow-up. Forty-eight-percent of the participants had normal weight, 41.9% had overweight, and 9.3% had obesity. Metabolically healthy status was found in 31.1% of subjects with normal weight and in 20.0% of those with overweight/obesity. During the follow-up, there were 108 MARCE. In multivariate Cox analysis adjusted for confounders and risk factors, no association was found between MARCE and overweight/obesity (p = 0.49). In contrast, metabolic status considered as a two-class variable (0 versus at least one metabolic abnormality) was a significant predictor of MARCE (HR, 2.11; 95%CI, 1.21-3.70, p = 0.009). Exclusion of atrial fibrillation from MARCE (N = 87) provided similar results (HR, 2.11; 95%CI, 1.07-4.16, p = 0.030). Inclusion of average 24 h BP in the regression model attenuated the strength of the associations. Compared to the group with healthy metabolic status, the metabolically unhealthy overweight/obesity participants had an increased risk of MARCE with an adjusted HR of 2.33 (95%CI, 1.05-5.19, p = 0.038). Among the metabolically healthy individuals, the CV risk did not differ according to BMI group (p = 0.53).

CONCLUSION

The present data show that the risk of MARCE is not increased in young metabolically healthy overweight/obesity suggesting that the clinical approach to people with high BMI should focus on parameters of metabolic health rather than on BMI.

Orthostatic Hypertension: A Newcomer Among the Hypertension Phenotypes

The prognostic role and the clinical significance of orthostatic hypertension (OHT) remained undefined for long because data were sparse and often inconsistent. In recent years, evidence has been accumulating that OHT is associated with an increased risk of masked and sustained hypertension, hypertension-mediated organ damage, cardiovascular disease, and mortality. Most evidence came from studies in which OHT was defined using systolic blood pressure (BP) whereas the clinical relevance of diastolic OHT is still unclear. Recently, the American Autonomic Society and the Japanese Society of Hypertension defined OHT as an orthostatic systolic BP increase ≥20 mm Hg associated with a systolic BP of at least 140 mm Hg while standing. However, also smaller orthostatic BP increases have shown clinical relevance especially in people ≤45 years of age. A possible limitation of the BP response to standing is poor reproducibility. OHT concordance is better when the between-assessment interval is shorter, when OHT is evaluated using a larger number of BP readings, and if home BP measurement is used. The pathogenetic mechanisms leading to OHT are still controversial and may vary according to age. Excessive neurohumoral activation seems to be the main determinant in younger adults whereas vascular stiffness plays a more important role in older individuals. Conditions associated with higher activity of the sympathetic nervous system and/or baroreflex dysregulation, such as diabetes, essential hypertension, and aging have been found to be often associated with OHT. Measurement of orthostatic BP should be included in routine clinical practice especially in people with high-normal BP.

Exaggerated blood pressure response to standing in young-to-middle-age subjects: prevalence and factors involved

PURPOSE

To investigate the prevalence of orthostatic hypertension and the association of the blood pressure (BP) level, supine BP decline, and white-coat effect with the orthostatic pressor response.

METHODS

We studied 1275 young-to-middle-age individuals with stage-1 hypertension. Orthostatic response was assessed three times over a 3 month period. The white-coat effect was assessed at baseline and after 3 months, and was calculated as the difference between office and average 24 h BP. In 660 participants, urinary epinephrine and norepinephrine were also measured.

RESULTS

An orthostatic systolic BP increase ≥ 20 mmHg was observed in 0.6-1.2% of the subjects during the three visits. Using the 20 mmHg cut-off, the prevalence of orthostatic hypertension was 0.6%. An orthostatic BP increase of ≥ 5 mmHg was found in 14.4% of participants. At baseline, the orthostatic response to standing showed an independent negative association with the supine BP level (p < 0.001), the supine BP change from the first to third measurement (p < 0.001), and the white-coat effect (p < 0.001). Similar results were obtained in the 1080 participants assessed at the third visit. Urinary epinephrine showed higher values in the top BP response decile (systolic BP increase ≥ 6 mmHg, p = 0.002 versus rest of the group).

CONCLUSION

An orthostatic systolic BP reaction ≥ 20 mmHg is rare in young adults. However, even lower BP increases may be clinically relevant. The BP level, the supine BP decline over repeated measurement, and the white-coat effect can influence the estimate of the BP response to standing and should be considered in clinical and pathogenetic studies.

Sleep-related factors associated with masked hypertension: the Nagahama study

OBJECTIVES

Masked hypertension, which is characterized by out-of-office hypertension but normal office blood pressure, is a risk factor for cardiovascular disease. However, the factors that contribute to masked hypertension are unclear. We aimed to determine the involvement of sleep-related characteristics in masked hypertension.

METHODS

The study included 3844 normotensive (systolic/diastolic blood pressure < 140/90 mmHg) community residents with no antihypertensive drug use at baseline (mean age 54.3 years). Home morning and evening blood pressure, oxygen desaturation during sleep (pulse oximetry), and sleep efficiency (actigraphy) were measured for 1 week. The number of nocturnal urinations during this period was obtained using a sleep diary.

RESULTS

Masked hypertension (mean morning and evening blood pressure ≥135/85 mmHg) was detected in 11.7% of study participants, and 79.0% of the participants with masked hypertension had sleep hypertension (≥120/70 mmHg). Multinominal logistic regression analysis identified different factors involved in masked hypertension with and without sleep hypertension; factors for masked hypertension with sleep hypertension included the frequency of at least 3% oxygen desaturation (coefficient = 0.038, P  = 0.001), nocturia (coefficient = 0.607, P  < 0.001), and carotid intima-media thickness (coefficient = 3.592, P  < 0.001). Only carotid intima-media thickness and measurement season were associated with masked hypertension without sleep hypertension. Low sleep efficiency was associated with isolated sleep hypertension but not masked hypertension.

CONCLUSION

Sleep-related factors associated with masked hypertension differed depending on the presence of sleep hypertension. Sleep-disordered breathing and nocturnal urination frequency may help identify individuals who need home blood pressure monitoring.